Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Landmark Of Amarillo Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with major depressive disorder, intact cognition, and bilateral below-knee amputations sustained a self-inflicted left wrist laceration after gaining access to a double-edged razor blade in his room. Staff found him bleeding in bed, and the resident gave inconsistent explanations about how the injury occurred. The hospital documented a laceration requiring sutures, and facility records noted the resident had an immediate threat to self-harm.
A resident with major depressive disorder, intact cognition, and a history of self-harm was found with a self-inflicted wrist laceration and sent to a behavioral health hospital for inpatient treatment. The facility issued an immediate discharge and staff stated corporate had decided not to take him back, even though the written policy says residents sent emergently to the hospital are generally expected to return unless discharge criteria are met. Interviews showed conflicting statements about whether the resident would be readmitted after psych treatment.
Dining Room Meal Service Failed to Treat a Resident with Dignity: A resident with dementia, dysphagia, and severely impaired cognition was seated with tablemates for lunch but did not receive her tray at the same time as the others. The other residents at her table began eating while she remained unserved, and she stated she felt left out and wondered why she did not get her food. The DM confirmed that all residents at a table should be served at the same time.
A resident with severe cognitive impairment, COPD, seizures, hemiplegia, and depressive disorder had used washcloths with brown discoloration left in her room’s shower area across repeated observations. The CN said the washcloths should have been removed, an LVN said dirty washcloths can cause cross-contamination and germs, and the DON stated CNAs should ensure rooms are clean, tidy, and free of trash.
Inaccurate MDS Diagnosis Coding: An MDS assessment for a resident with Parkinson's disease, dementia, and anxiety disorder incorrectly coded bipolar disorder as an active diagnosis even though it was not listed in the admission record, care plan, or diagnosis report. Staff, including the MDS RN, stated the MDS RN completed assessments and acknowledged she was unsure why the diagnosis was coded.
A resident with a documented diagnosis of major depressive disorder recurrent severe was not referred for a new PASRR Level II review after the qualifying diagnosis was identified. The record showed a prior PASRR Level 1 screen was negative for MI, but no Form 1012 was completed despite the diagnosis and multiple antidepressant orders tied to depression. Staff interviews confirmed PASRR screenings were expected after a qualifying change in diagnosis, and the MDS RN stated she was responsible for ensuring they were completed.
A resident with schizoaffective disorder, anxiety, and major depressive disorder was admitted with an inaccurate PASRR PL1 that coded no mental illness. The PL1 was completed by a family member, and staff interviews showed the MDS RN and AC were responsible for ensuring PL1 accuracy, but the AC did not verify the form against the resident’s diagnoses. Facility policy required the PL1 to be obtained and reviewed for correctness before admission.
A resident with COPD, dementia, DM2, CHF, and morbid obesity was observed receiving O2 via nasal cannula at 2 lpm even though the chart contained no physician order for oxygen therapy and no MAR documentation for oxygen flow rate or dosage. The care plan referenced giving oxygen as ordered by the physician, but the O2 saturation record showed oxygen administration over several days, and staff and the DON acknowledged that oxygen is a medication requiring a provider order.
A cook prepared pureed menu items by adding unmeasured gravy, BBQ sauce, and multiple slices of bread to green beans, BBQ chicken, and rolls, rather than following standardized puree recipes. Taste tests showed the foods tasted like bread, gravy, or had an overwhelming BBQ sauce flavor. The RD stated proper thinning methods included chicken broth, vegetable juice, or milk, and the resident on the pureed diet reported the bread tasted like gravy, the chicken had too much BBQ sauce, and the green beans tasted like bread.
Improper Hair Restraints in Kitchen: Staff were observed in the kitchen without proper hairnets and beard covers, and one staff member's beard cover did not fully cover his beard, sideburns, or moustache. Another staff member walked through the kitchen without any hairnet or beard cover and said he was not sure he was supposed to put it on. The RD and DM stated all staff were expected to wear hairnets and beard covers at all times, and facility policies required hair restraints and facial hair coverage.
A resident with chronic respiratory failure, asthma, cerebral infarction, and dementia had an oxygen order via N/C, but his nasal cannula was observed left on the floor with the prongs touching the floor for an extended period. Staff interviews confirmed rounds were expected every 2 hours and that oxygen tubing should be stored off the floor, yet the cannula remained in place through multiple observations and was not addressed until later when a new cannula was found hanging from the concentrator.
A facility failed to maintain an accurate system for recording and reconciling the receipt and distribution of a controlled substance, OxyContin ER 10mg, for a resident with chronic pain. Although the medication was signed for by an LVN and the pharmacy driver, staff could not confirm whether the medication was actually received or properly distributed, and there was no documentation from the nurse responsible for the resident's unit. Administrative staff and the pharmacy driver acknowledged gaps in the process, and the required accountability record was not completed.
A resident with a seizure disorder received an incorrect dosage of Lamotrigine due to an error in entering physician orders. The ADON failed to update the dosage correctly in the MAR, resulting in the resident receiving 500 mg instead of the prescribed 250 mg. The error was discovered when the resident was sent to the hospital, and the facility's process for entering medication orders was not followed correctly.
The facility's kitchen failed to maintain sanitary conditions, with issues such as improper labeling and dating of food, staff not wearing hairnets, and improper storage of frozen foods. Observations revealed opened and improperly stored food items, and a cooler not maintaining the correct temperature. The dietary manager acknowledged these issues, which were against the facility's policies.
The facility failed to properly store and label medications, with instances of unattended medications, expired drugs, and missing open dates on inhalers. Staff interviews highlighted awareness of potential negative outcomes, such as drug diversion and ineffective treatment. The facility's policies were not adequately followed, posing risks to residents.
A resident with severe cognitive impairment and PTSD did not receive trauma-informed care due to the absence of a documented trauma assessment in his clinical file. Interviews with facility staff revealed that trauma assessments were expected upon admission, but the Social Worker was unsure if it had been completed due to a change in facility ownership. The facility's policy emphasized individualized care plans for trauma survivors, which was not implemented for this resident.
The facility failed to maintain effective infection control practices, as observed in the care of two residents. A resident's catheter bag and tubing were not kept off the floor and below waist level, contrary to the care plan, and the resident reported not receiving proper education on catheter care. Additionally, staff failed to perform hand hygiene and glove changes during incontinent and catheter care, leading to potential cross-contamination. These actions were inconsistent with the facility's infection control policies.
Resident Accessed Razor Blade and Sustained Wrist Laceration
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that the resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was admitted with diagnoses including type 2 diabetes mellitus, nicotine dependence, alcohol dependence in remission, major depressive disorder recurrent severe, alcoholic hepatitis, and bilateral below-knee amputations. His quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was independent with most ADLs except bathing, where he needed supervision or touching assistance. His care plan addressed major depressive disorder and included monitoring for risk of harm to self, suicidal plan, past attempt at suicide, risky actions, refusal of food or medications, hopelessness, helplessness, and impaired judgment or safety awareness. On the night of the incident, staff found Resident #1 in his room bleeding from a self-inflicted wound to his left wrist. Nursing documentation stated he had a laceration to the inside of the left wrist and required emergency transfer to the hospital. The resident told staff that he cut himself, and later gave varying explanations, including that he was throwing away razor blades and slipped. Staff documented that a metal box containing barber razors and a marijuana vape pen was found in the resident’s trash can. The hospital discharge instructions documented a laceration to the left wrist requiring suture repair, and the facility discharge notification stated the resident had an immediate threat to self-harm and that he lacerated his wrist with a double edged razor blade. Interviews with multiple CNAs, LPNs, the DON, and the ADON confirmed that residents were not supposed to have razor blades in their rooms because they could hurt themselves or others, and that CNAs shaved residents who wanted to be shaved. Staff also stated they had not noticed suicidal ideation or depression in the resident before the event. The facility’s records included an undated list of items not allowed in resident rooms that identified razors and blades as safety hazards, but the resident still had access to a double-sided razor blade that was used in the wrist injury. The report states the noncompliance was identified as past noncompliance with immediate jeopardy and that the facility had instituted adequate corrective measures to prevent recurrence.
Failure to Follow Return-from-Hospital Policy
Penalty
Summary
The facility failed to establish and follow its written policy for permitting a resident to return after hospitalization or therapeutic leave for one resident reviewed for transfer/discharge rights. The resident had diagnoses including type 2 diabetes mellitus, nicotine dependence, alcohol dependence in remission, major depressive disorder recurrent severe, alcoholic hepatitis, and bilateral below-knee amputations. His quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was receiving antidepressant medication. His care plan addressed major depressive disorder and included monitoring for risk of self-harm, suicidal plan or past attempt, risky actions, hopelessness, impaired judgment, and safety awareness. The resident was found in his room bleeding from a self-inflicted wrist wound after using a straight razor. He was placed on one-on-one supervision and then transferred to a behavioral health hospital for inpatient treatment after staff and administration determined he needed psychiatric evaluation and admission because of the seriousness of the injury. The facility completed an immediate discharge notice and discharge notification stating the discharge was necessary for his welfare and that his needs could not be met in the facility, and that he had an immediate threat to self-harm. Survey interviews showed the facility had decided not to take the resident back after his psychiatric hospitalization. The OM stated she was concerned the facility might not plan to readmit him, and later stated ADM told her the decision came from corporate and that the facility did not intend to take him back. ADM stated corporate had decided, "we are not taking him back," and said she would help the behavioral hospital find placement if needed. DDC later stated the immediate discharge did not necessarily mean the resident could not return, but ADM also stated the reason for the immediate discharge rather than a transfer was that the facility was not intending to take him back. The facility policy stated that residents sent emergently to the hospital are considered facility-initiated transfers because return is generally expected, and that the facility will allow residents to return following hospitalization unless discharge conditions are met.
Dining Room Meal Service Failed to Treat a Resident with Dignity
Penalty
Summary
The facility failed to ensure Resident #56 had a dignified dining room experience when she did not receive her noon meal at the same time as the other residents seated at her table. Resident #56 was a 95-year-old female with diagnoses including dementia, diabetes, dysphagia, vitamin B deficiency, and vitamin D deficiency. Her care plan documented that she was independent in most ADLs, wandered, and was at risk for falls, and her quarterly MDS showed a BIMS score of 5 out of 15, indicating severely impaired cognition. The MDS also documented that she usually understood what was said to her and was usually understood. During observation, Resident #56 was seated at the dining table with two tablemates, but the other residents received their trays and began eating while she was not served. She remained without her lunch until after the two tablemates and two other tables of four residents each had already received their food. In interview, Resident #56 stated she felt left out and had been wondering why she did not get her food, and said she thought she might not get to eat. The DM stated she had not been aware the resident had not received her tray at the same time as the rest of the residents at her table and confirmed that all residents at a table should be served at the same time.
Soiled Washcloths Left in Resident Room
Penalty
Summary
The facility failed to provide a safe and clean environment for Resident #59 when used washcloths were left in her room for an extended period. Resident #59 was a severely cognitively impaired female resident with diagnoses including COPD, seizures, hemiplegia, and depressive disorder. Her quarterly MDS showed a BIMS of 07 and indicated she was dependent on staff for most ADLs. Her care plan also identified a behavior problem with a history of finger-painting feces and directed staff to check often for position and cleanliness. During multiple observations, several used washcloths with slight brown discoloration were seen in a brown bin in the shower area of Resident #59's room and remained there across repeated checks. On one observation, the CN stated the soiled washcloths were an issue, did not know why they were in the shower because the shower was not used for resident care, and said they should have been removed. An LVN stated dirty washcloths should be removed because they were dirty and could lead to cross-contamination and germs. A CNA reported staff make rounds every 2 hours and check rooms for cleanliness, and the DON stated CNAs should ensure resident rooms are clean, tidy, and free of trash.
Inaccurate MDS Diagnosis Coding
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for 2 of 18 residents reviewed for assessment accuracy. For Resident #18, the admission record dated 03/25/26 showed diagnoses including Parkinson's disease, dementia, and anxiety disorder, but did not show bipolar disorder. However, the resident's significant change MDS assessment completed on 01/25/26 listed bipolar disorder in Section I, Active Diagnoses in the Last 7 Days. The resident's care plan completed on 01/25/26 and the diagnosis report dated 03/25/26 also did not mention bipolar disorder. During interviews, RN D, ADON, DON, ADM, and CN stated the MDS RN was responsible for completing MDS assessments and that an inaccurate assessment could affect the resident's care or cause needed care to be missed. The MDS RN stated she was responsible for completing MDS assessments, used the RAI manual as her policy, and was not sure why Resident #18 was coded as having bipolar disorder. The facility policy required complete and accurate documentation for each resident, and the RAI Manual stated Section I active diagnoses must reflect diagnoses with a direct relationship to the resident's current status during the 7-day look-back period.
Failure to Complete PASRR Referral After Qualifying Mental Health Diagnosis
Penalty
Summary
The facility failed to refer Resident #9 to the state designated authority for a PASRR Level II resident review after a qualifying diagnosis of major depressive disorder, recurrent severe was documented. Resident #9 was admitted with diagnoses including personal history of traumatic brain injury and major depressive disorder recurrent severe, and the record showed the major depressive disorder diagnosis had been made on 02/28/25. His quarterly MDS completed on 02/02/26 showed a BIMS score of 6 and listed depression as an active diagnosis. The record also showed multiple antidepressant medication orders tied to major depressive disorder recurrent severe, including duloxetine, mirtazapine, and sertraline, with several dose changes and discontinuations over time. Review of the EHR miscellaneous tab revealed one PASRR screening and no Form 1012. The PASRR Level 1 Screening dated 12/09/24 showed the resident was negative for mental illness. During interviews, RN D, ADON, DON, ADM, CN, MDS RN, and PC all discussed that PASRR screenings should be completed when needed after admission and that failure to complete a new screening after a qualifying diagnosis could negatively affect resident care. The MDS RN stated she was responsible for ensuring PASRR screenings were done as needed after admission, but also stated she did not think the resident's care would be negatively impacted because residents with mental illness received in-house treatment, while acknowledging that without a new PASRR screening residents would not be offered the opportunity to get outside services. Facility policy stated Form 1012 is completed when an individual's diagnosis is changed and that depression is not considered a mental illness unless diagnosed as major depressive disorder in the medical record by the physician.
Inaccurate PASRR PL1 Screening for Resident with Mental Health Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not performed accurately for one resident prior to admission. The resident was admitted with diagnoses including schizoaffective disorder, bipolar type, generalized anxiety disorder, and major depressive disorder, and the record also showed a BIMS score of 12 with active diagnoses of anxiety disorder, depression, and schizophrenia on the MDS. Her care plan identified depression related to schizophrenia and included antidepressant, antipsychotic, and anti-anxiety medications, and her active orders included aripiprazole and divalproex sodium related to schizoaffective disorder, bipolar type. The resident’s PL1 in the EHR was completed by a family member and coded her as having no mental illness. Staff interviews showed the MDS RN and AC were responsible for ensuring PL1s were completed at or prior to admission, while the AC stated she sent the PL1 to the MDS RN without checking it against the resident’s diagnoses. Facility policy required the PL1 to be obtained on or before admission and reviewed for completion and correctness before admission, and another policy stated depression is not considered a mental illness unless diagnosed as major depressive disorder in the medical record by the physician.
Oxygen Administered Without Physician Order
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for one resident with COPD, dementia, type 2 diabetes, a history of myocardial infarction, acute on chronic diastolic heart failure, and morbid obesity. The resident’s most recent MDS showed a BIMS score of 10 and indicated substantial to maximal assistance with most ADLs. The resident’s care plan identified shortness of breath related to COPD and included an intervention to give oxygen therapy as ordered by the physician, but the Order Summary and MAR contained no physician orders for oxygen therapy and no documentation for oxygen administration, including flow rate or dosage. Despite the absence of an oxygen order, the O2 Saturation Summary documented oxygen administration via nasal cannula from 03/21/2026 through 03/25/2026. Staff observations also showed the resident receiving oxygen via nasal cannula at 2 lpm while sitting in a recliner, eating lunch, lying in bed asleep, and later lying in bed receiving oxygen. During interviews, CNA F stated nurses were responsible for setting flow rates, LVN E stated there were no oxygen orders and that oxygen is considered medication requiring a physician order, LVN G stated oxygen without an order could cause adverse reactions due to the absence of a baseline for comparison, and the DON stated oxygen should not be administered without a physician’s order. The facility policy stated that the amount and method of oxygen administration are ordered by the physician.
Pureed Meals Prepared With Unmeasured Ingredients and Improper Thickeners
Penalty
Summary
The facility failed to prepare and serve pureed foods using standardized recipes and nutritive methods to ensure palatability and flavor for a resident on a pureed diet. During observation, a cook measured green beans with juice, gravy, and multiple slices of bread into a blender, then added more bread during the puree process. The resulting green beans tasted like bread with a hint of gravy, and the cook stated she used gravy because it was already made and bread because it made the food taste better. She also stated she did not review the puree recipes, and no recipes were out for review in the kitchen at the time. The cook also pureed BBQ chicken by adding an unmeasured amount of BBQ sauce, then more BBQ sauce and several slices of bread before completing the puree. A taste test showed the chicken had a strong, overwhelming taste of BBQ sauce, and the cook again stated it was ok. When pureeing honey kissed rolls, the cook microwaved the rolls, placed the whole package in the blender, and added multiple scoops of gravy before pureeing again. The bread tasted like gravy, and the cook stated she used gravy because it was already made. She stated she had not used milk to puree bread. The RD stated purees should be thinned with chicken broth for chicken, juice from green beans or chicken broth for vegetables, and milk for bread, and that measured amounts of liquid should be used only as needed after an initial puree. The RD also stated gravy was not a usual thinner and that if green beans were drained properly there would be no need to add gravy or bread. The DM stated cooks had been trained to puree foods and taste them after preparation to ensure quality, and that foods should be pureed first with no added liquid, then small measured amounts of liquid added as needed. The resident who received the pureed lunch stated the bread tasted like gravy, the chicken had too much BBQ sauce, and the green beans tasted like bread.
Improper Hair Restraints in Kitchen
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when staff did not wear proper hair restraints and beard guards while in the kitchen. A posted sign on the main kitchen door stated that a hairnet must be worn at all times in the kitchen and that no one should enter without putting one on. During an observation, one staff member walked through the kitchen with his beard and sideburns sticking out of his beard cover, and the beard cover did not cover his mouth, sideburns, or the upper part of his beard. He stated he believed he was supposed to have a beard cover and hairnet on while in the kitchen, but when asked about the uncovered hair he said, "What am I supposed to do about that?" Later, another staff member walked into the kitchen from the front door and through the kitchen to the staff changing room without a hairnet or beard cover. He stated he had just walked through the kitchen and was not sure he was supposed to put it on. The RD stated she expected all staff to wear hairnets and beard covers at all times while in the kitchen and that they should cover all hair. The DM stated she had trained staff in kitchen duties and expected all staff to wear hairnets and beard covers, and she was aware the beard cover had not covered one staff member's beard and moustache very well. Facility policies stated that hairnets and beard restraints are worn when cooking, preparing or assembling food, that hairnets or hats covering the hairline are worn at all times, and that facial hair is to be covered with an effective hair restraint.
Oxygen Nasal Cannula Left on Floor
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #65 when his oxygen nasal cannula was left on the floor for an extended period of time. Resident #65 was a male resident with chronic respiratory failure, asthma, cerebral infarction, and dementia, and his quarterly MDS showed a BIMS score of 15 with supervision to partial/moderate assistance needed for activities of daily living. His care plan included oxygen therapy, and his active order directed oxygen at 2-5 L via nasal cannula every shift to keep O2 saturations greater than 88%. During observation, Resident #65 was not in his room, and his nasal cannula was found on the floor next to the oxygen concentrator and bedside dresser with the prongs touching the floor. Later observations showed the cannula remained in the same position while the resident was on the unit in his wheelchair, then while he was in bed with the head of bed elevated, and again later that day under a trash can after the trash had been emptied. The cannula continued to remain on the floor into the next day, still in the same area next to the dresser and oxygen concentrator. During interview, Resident #65 stated he had pneumonia about a month ago and required oxygen but only used it at night now, and he said staff provided all his needs including oxygen care. An LVN stated staff should make rounds every 2 hours, check oxygen tubing to ensure it was stored correctly in a bag off the floor, and replace tubing found on the floor before using it. The LVN also stated the tubing should have been caught by staff during rounds. The DON and CNA reported staff should make rounds every two hours and ensure the nasal cannula and tubing were stored in a bag off the floor, and the CN stated the facility did not have a policy or procedure specific to nasal cannula storage.
Failure to Accurately Account for Receipt and Disposition of Controlled Drugs
Penalty
Summary
The facility failed to establish and maintain an adequate system for recording the receipt and disposition of controlled drugs, specifically OxyContin ER 10mg, for one resident. The medication was documented as received from the pharmacy, with signatures from both the LVN and the pharmacy driver, but there was no accurate reconciliation or detailed record to confirm the medication was actually received and properly distributed. The process for checking in and distributing controlled substances was inconsistent, with staff unable to verify whether the medication was present or delivered to the correct unit. The resident involved was an adult male with a history of cauda equina syndrome, chronic pain syndrome, a displaced fracture, and benign prostatic hyperplasia. His care plan included scheduled opioid pain medication, and his medication administration record indicated he received pain medication daily. However, interviews with staff revealed uncertainty about the actual receipt and distribution of the OxyContin, with the responsible LVN unable to confirm if the medication was included in the delivery or handed off to the nurse responsible for the resident's unit. There was no documentation or signature from the second LVN to confirm receipt of the medication. Administrative staff, including the ADM and ADON, acknowledged the lack of an accurate process for receiving and reconciling controlled medications. The pharmacy driver also confirmed that, prior to the incident, he did not observe the nurse count in the medications upon delivery. The facility's policy required a controlled medication accountability record to be prepared upon receipt, but this procedure was not followed, resulting in an inability to account for the controlled substance in question.
Medication Administration Error Due to Incorrect Order Entry
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for a resident, leading to incorrect medication administration. The resident, who had a history of seizures and was admitted to the facility from the hospital, was prescribed Lamotrigine to manage her condition. However, due to an error in entering the physician's orders, the resident received an incorrect dosage of the medication. Specifically, the resident was given 500 mg of Lamotrigine in the morning instead of the prescribed 250 mg, as the order was mistakenly entered as 200 mg tablets instead of 100 mg tablets. The error occurred because the Assistant Director of Nursing (ADON) did not update the dosage correctly in the Medication Administration Record (MAR) after being advised by the pharmacy to adjust the order to match the available tablet sizes. As a result, the resident received an excessive dose of Lamotrigine for several days, which was discovered when the resident was sent back to the hospital due to a bleeding head wound. Although the pharmacist indicated that the excess dosage would not cause hospitalization, it was noted that the resident's Lamotrigine blood level was slightly above the normal range. Interviews with the ADON and the Director of Nursing (DON) revealed that the facility's process for entering medication orders at admission was not followed correctly, leading to the medication error. The facility's policy requires that new medication orders be accurately transcribed to the MAR, but this was not done in this case. The DON acknowledged that incorrect medication entry could result in medication errors, potentially affecting the effectiveness of the treatment provided to residents.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. The deficiencies included improper labeling and dating of stored food, failure to wear hairnets by kitchen staff, and improper storage of frozen foods. Specifically, a dietary aide was seen washing dishes without a hairnet, citing an inability to find one, despite being trained to always wear one to prevent cross-contamination. Additionally, the cooler in the kitchen preparation area contained opened and improperly stored food items, such as crinkle cut fries and corndogs, which were not kept frozen as required by their labels. Further observations revealed that the walk-in freezer contained several items that were either unlabeled, undated, or uncovered, including cherry pie bites, bags of biscuits, and a cooked pumpkin pie. The dietary manager acknowledged these issues, stating that the food should have been labeled, dated, and covered, and that the cooler, which was supposed to function as a freezer, was not maintaining the correct temperature. The facility's policies from 2012 outlined the requirements for food storage and sanitation, including the use of hairnets and proper labeling and dating of food items, which were not adhered to in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and labeled according to professional principles. Medications were left unattended on top of a medication cart by an LVN, posing a risk of access by other residents. Additionally, expired medications were found on the 2C South medication cart and in the medication room refrigerator, including insulins and acetaminophen suppositories. Loose pills were also discovered on medication carts, and several inhalers lacked open dates, which are necessary to determine their expiration. Interviews with staff revealed awareness of the potential negative outcomes of these deficiencies, such as drug diversion, lack of drug efficacy, and adverse reactions. The staff acknowledged that leaving medications unattended could result in unauthorized access by residents, and administering expired medications could lead to ineffective treatment. The absence of open dates on medications could result in their use beyond the manufacturer's recommended period, compromising their effectiveness. The facility's policies on medication storage and discontinuation were reviewed, revealing a lack of adherence to procedures for dating medications upon opening and removing discontinued medications from storage. The facility did not provide a specific policy for medication cart or medication room storage, indicating a gap in their procedural framework. These deficiencies collectively placed residents at risk for medication errors and adverse health outcomes.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident with a history of trauma, specifically post-traumatic stress disorder (PTSD). The resident, a male with severe cognitive impairment and PTSD, did not have a trauma screening or assessment documented in his clinical file. This lack of documentation meant that the resident's care plan did not include any interventions to address his PTSD, which could potentially lead to re-traumatization. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), Social Worker (SW), Director of Nursing (DON), Clinical Resource Nurse (CRN), and Assistant Director of Nursing (ADON), revealed that trauma assessments were expected to be completed upon admission. However, the SW was unsure if the assessment had been completed due to a change in facility ownership. The facility's policy on trauma-informed care emphasized the importance of collaborating with trauma survivors to develop individualized care plans, but this was not implemented for the resident in question.
Infection Control Deficiencies in Catheter and Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved Resident #27, whose catheter bag and tubing were not consistently kept off the floor and below waist level, contrary to the care plan and facility policy. Observations revealed that the catheter bag was placed on the floor and above waist level, which could lead to potential infections. Despite the care plan indicating that staff should educate the resident on proper catheter care, Resident #27 reported not receiving such education, and staff interviews suggested challenges in redirecting the resident's behavior. Another deficiency was noted in the care provided to Resident #11, where CNA G failed to perform hand hygiene and change gloves between cleaning the resident's soiled buttocks and placing a clean brief. This lapse in infection control practices was acknowledged by CNA G, who admitted that such actions could lead to infections. The facility's infection control plan requires staff to wash their hands after each direct resident contact, but this was not adhered to during the observed care. Additionally, CNA C was observed not performing hand hygiene after removing gloves and before putting on new ones while providing catheter care to Resident #27. CNA C also placed a brief that had been on the floor onto a bedside table for later use, which could lead to cross-contamination. Interviews with facility staff, including the DON and ADON, confirmed that these actions could result in a lack of infection control. The facility's policies on catheter care and infection control were not followed, contributing to the deficiencies observed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ussery Roan Texas State Veterans Home | 0.6 mi | ★★★★★ | 0 | 0 |
| Amarillo Medical Lodge | 0.6 mi | ★★★★★ | 4 | 0 |
| Windflower Health Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Heritage Convalescent Center | 0.8 mi | ★★★★★ | 9 | 0 |
| Amarillo Center For Skilled Care | 1.4 mi | ★★★★★ | 8 | 0 |
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